Healthcare Provider Details

I. General information

NPI: 1447565874
Provider Name (Legal Business Name): GHAZI SAMIR IDRISS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 ORANGETHORPE AVE STE 3
BUENA PARK CA
90621-4660
US

IV. Provider business mailing address

7212 ORANGETHORPE AVE STE 3
BUENA PARK CA
90621-4660
US

V. Phone/Fax

Practice location:
  • Phone: 714-562-0966
  • Fax: 888-789-3197
Mailing address:
  • Phone: 714-562-0966
  • Fax: 888-789-3197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number31620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: